This section discusses the major tobacco related disease groups leading to illness and death among Australia’s Aboriginal and Torres Strait Islander peoples, and highlights differences, where they occur, from the general Australian population. The health consequences of smoking are discussed in detail in Chapter 3. National figures on morbidity and mortality due to smoking are provided in Chapter 3, Section 3.30.

8.7.1 Causes of mortality and morbidity among Aboriginal and Torres Strait Islander peoples

Aboriginal and Torres Strait Islander peoples experience poorer health outcomes and have a lower life expectancy than the rest of the Australian population. In 2010–12, life expectancy for Aboriginal and Torres Strait Islander males was estimated to be 10.6 years lower than that for non-Indigenous males (69.1 years compared with 79.7 years) and 9.5 years lower for females (73.7 compared with 83.1 years). Between 2005–07 and 2010–12, life expectancy increased for both Indigenous men and women, and the life expectancy gap between Indigenous and non-Indigenous Australians reduced slightly, by 0.8 years for males and by 0.1 years for females. During the period 2011–15, in NSW, Qld, WA, SA, and the NT (jurisdictions where there was adequate data), the all causes mortality rate was 1.7 times as high for Aboriginal and Torres Strait Islander peoples as the rate for non-Indigenous Australians. Most deaths for Aboriginal and Torres Strait Islander peoples occur in the middle age groups, while most deaths for the non-Indigenous population occur in the older age groups.1

In 2011–15, the most common cause of death among Aboriginal and Torres Strait Islander peoples was circulatory diseases (24% of all deaths), followed by neoplasms (including cancer; 21%) and external causes (including suicide, car accidents, poisoning, assault, and drowning; 15%;). Circulatory diseases accounted for the largest gap in death rates (24% of the gap), followed by endocrine, metabolic and nutritional disorders (including diabetes; 19%); neoplasms (including cancer; 15%); and respiratory diseases (12%). Deaths due to diabetes alone were 5.6 times higher for Indigenous Australians than for non-Indigenous Australians.1

In 2011–15, 61% of deaths among Indigenous people aged 0–74 years were from avoidable causes (i.e., deaths from conditions that could either be prevented from occurring at all, or that could be avoided with early diagnosis and effective treatment), compared with 50% of non-Indigenous deaths in the same age group. Aboriginal and Torres Strait Islander peoples died from all avoidable causes at 3.3 times the rate of non-Indigenous Australians; although, encouragingly, there was a 32% decline in the avoidable mortality rate for Aboriginal and Torres Strait Islander peoples in the period 1998 to 2015.1 Chronic disease and injury are responsible for the greatest proportion of avoidable Indigenous deaths, and are responsive to both prevention and treatment.2

A 2016 study analysed mortality and morbidity data from 2011 to assess the ‘burden of disease’ of various conditions for Indigenous people.3 The ‘burden of disease’ incorporates measures of both mortality (years of life lost due to premature death), and morbidity (years lived with disability), and is expressed in terms of disability-adjusted life years (DALYs). Table 8.7.1 shows the leading causes of DALYs for Indigenous males and females. In 2011, coronary heart disease, alcohol use disorders, and suicide and self-inflicted injuries were the top three contributors to the burden of disease for Indigenous males, while for Indigenous females, the leading causes of burden were anxiety disorders, coronary heart disease, and depressive disorders. Coronary heart disease, anxiety disorders, and diabetes were ranked in the top 5 diseases for both sexes. After adjusting for differences in age structure, Indigenous Australians experienced overall burden from disease and injury at 2.3 times the rate of non-Indigenous Australians.3

The Australian burden of disease study provides details on the burden attributable to the leading risk factors for Indigenous Australians. In 2011, tobacco use (including past tobacco use, current use, and exposure to second-hand smoke in the home) accounted for 12.3% of the burden of disease, more than any of the other risk factors, and more than for alcohol and illicit drugs combined. This proportion appears largely unchanged from the previous burden of disease study in 2003, when tobacco use accounted for 12.1% of the total burden.4 In 2011, tobacco use was responsible for 23.3 per cent of the gap in disease burden between Indigenous and non-Indigenous Australians. Coronary heart disease was the leading disease outcome attributable to tobacco use, followed by chronic obstructive pulmonary disease (COPD), lung cancer, and stroke. Tobacco caused 93 per cent of the lung cancer burden, 87 per cent of the COPD burden, 71 per cent of the oesophageal cancer burden, and 64 per cent of the mouth and pharyngeal cancer burden. Across all disease outcomes, the large majority (81 per cent) of the burden was due to premature mortality, although this varied substantially by disease. For example, premature death made up almost all of the attributable liver, oesophageal, and lung cancer burden but only 6 per cent of the asthma burden. The overall burden attributable to tobacco use increased with age, and was greater in males than females.3

It has been estimated that if all tobacco-caused deaths among Indigenous Australians could be eliminated, then average life expectancy would increase by 2.5 years for males and 1.7 years for females.5 While this may not seem very much, it is important to note that this estimate is averaged across the entire Indigenous population, smoker and non-smoker. If applied only to smokers it would be considerably greater.

Two earlier studies also attempted to quantify deaths due to smoking among Indigenous people. The Northern Territory study (1986–1995) found that smoking caused 23% of deaths among Indigenous males, and 17% of deaths among Indigenous females.6 In the non-Indigenous Northern Territory population, 22% of male deaths and 11% of female deaths were attributable to smoking. Regional differences in Indigenous smoking patterns (see also Section 8.3.1), meant that Indigenous people in the ‘Top End’ of the Northern Territory were more likely to die from disease caused by smoking compared to those living in the centre. Most deaths due to smoking were caused by COPD, ischaemic heart disease, lung cancer, stroke, pneumonia and oropharyngeal cancer.6Indigenous women had an age-adjusted smoking attributable death rate of 251 per 100,000; more than six times higher than that of non-Indigenous women (38 deaths per 100,000). The rate for Indigenous males was more than three times higher than that of their non-Indigenous counterparts (457 per 100,000 compared to 145 per 100,000).6

The Western Australian study (1983–1991) estimated that tobacco use caused 13% of all deaths among Aboriginal people, compared to 16% of all deaths in the Western Australian population. Ischaemic heart disease was the leading cause of death, followed by lung cancer and chronic bronchitis. Indigenous women died at almost four times the rate of non-Indigenous women (118 deaths per 100,000 compared to 32 per 100,000) and Indigenous men died from tobacco-caused illness at nearly two-and-a-half times the rate of non-Indigenous men (271 deaths per 100,000 compared to 113 per 100,000).7

Both reports note that death rates for tobacco-caused diseases increased substantially at an earlier age among Indigenous people than for non-Indigenous people. The Northern Territory study noted that increases in tobacco-caused morbidity occurred from 35 years of age compared with 45 years of age;6 the Western Australian report found that nearly half of all tobacco-caused deaths occurred before the age of 55 in the Indigenous population, compared to only about 11% of deaths in the non-Indigenous population.7

Data from the Australian Institute of Health and Welfare’s National Hospital Morbidity Database shows that Indigenous people are substantially more likely to be hospitalised due to illness caused by tobacco. In 2006–07 to 2007–08, Indigenous Australians had four times the rate of hospitalisations with a principal diagnosis related to tobacco use as non-Indigenous Australians. While Indigenous males were admitted to hospital at 3.2 times the rate for non-Indigenous males, Indigenous women had 5.1 times the admission rate of non-Indigenous women.8Similarly high rates have been found in earlier studies in the Northern Territory (1993–1995)6 and Western Australia (1983–1991).9

A study published in 2018 followed a cohort of 2,273 Aboriginal and Torres Strait Islander adults from 26 remote communities in far North Queensland over 15 years, who were initially free of cancer. Findings showed that at follow-up, smokers had a 60% higher risk for all cancers combined and a fourfold risk for lung cancers compared to non-smokers, regardless of age, sex and ethnicity.10

Researchers have also considered the current stage of the smoking epidemic among Indigenous Australians, and the short- and long-term implications. They suggest that the Indigenous population is at an earlier stage of the tobacco epidemic than the total Australian population, at Stage 3 versus Stage 4 (see Section 1.3.3), and that the burden of smoking-attributable mortality is likely to remain high. The burden of tobacco-related cardiovascular disease will likely decline in the short term as smoking prevalence continues to decline. The burden of lung cancer may peak within the next decade—assuming that peak smoking prevalence occurred at or before 1994—which reflects the long lag time between smoking behaviour and the onset of tobacco-related cancer mortality.11

8.7.3 Diseases and conditions related to smoking

Tobacco is a causal, contributing or complicating factor in many diseases and conditions disproportionately experienced by Indigenous people. This sub-section considers some of the specific diseases and conditions related to smoking: cardiovascular diseases, cancers, respiratory diseases, diabetes, and pregnancy-related conditions.

8.7.3.1 Cardiovascular diseases

In 2012–13, 13% of Indigenous Australians aged two and over reported having cardiovascular disease (CVD; a broad term for a range of diseases affecting the heart and blood vessels),12and in 2011–15 it was the leading cause of death among Aboriginal and Torres Strait Islander peoples, accounting for 24% of all deaths.1 The leading specific causes of CVD deaths were ischaemic heart disease (55%), followed by cerebrovascular causes such as stroke (17%);1 smoking increases the risk for each of these conditions.13 CVD was also responsible for the largest percentage (24%) of the mortality gap between Indigenous and non-Indigenous people in 2008–2012; however, between 1998 and 2012, there was a 40% decline in age-standardised death rates due to CVD for Indigenous people, and a 43% decline in the mortality gap. This has been largely due to decreases in deaths from coronary heart disease and cerebrovascular disease.12

The high prevalence of smoking, diabetes, obesity and sedentary lifestyle, high blood pressure and cholesterol, and poor nutrition in the Aboriginal and Torres Strait Islander populations contributes to the incidence of cardiovascular diseases in their communities. National14 and regional15-18 studies have shown a high incidence of multiple risk factors for heart disease among the Indigenous population, especially smokers.19 In 2004–05, 30% of current smokers and 37% of former smokers reported having heart or circulatory disease.19

8.7.3.2 Cancers

The Australian Institute of Health and Welfare’s 2018 report on cancer in Aboriginal and Torres Strait Islander people20 indicated that in 2009–13, Indigenous Australians were 1.1 times as likely to be diagnosed with cancer as non-Indigenous Australians. Lung cancer was the most commonly diagnosed cancer among Indigenous Australians, followed by breast cancer in women, colorectal cancer, and prostate cancer. Cancer type rankings varied for Indigenous and non-Indigenous Australians—Indigenous Australians had higher incidences of lung, head and neck, uterine, liver, and cervical cancers—reflecting Indigenous Australians’ higher prevalence of cancer-related modifiable risk factors (such as smoking and alcohol consumption), poorer access to health-care services, and lower uptake of diagnostics testing and national population-based screening programs (such as those for breast, cervical, and bowel cancer). Between 1998 and 2013, the incidence of non-Hodgkin lymphoma, lung, thyroid, uterine, and bowel cancers increased significantly among Indigenous Australians.

In 2007–2014, Aboriginal and Torres Strait Islander people diagnosed with cancer had a 50% chance, on average, of surviving five years compared to their non-Indigenous counterparts. In 2011–2015, Aboriginal and Torres Strait Islander people were 1.4 times as likely to die from cancer as non-Indigenous Australians. This difference may be due to Indigenous Australians’ higher likelihood of being diagnosed with cancers with poor prognoses (e.g., lung cancer and cancer of unknown primary site) or of being diagnosed at an advanced stage, and being less likely to receive adequate treatment. Lung cancer was responsible for the most cancer deaths among Indigenous Australians, followed by liver cancer, head and neck cancer, and cancer of unknown primary site. Due to the lower survival and higher mortality rates, the prevalence of cancer was lower among Indigenous than non-Indigenous Australians.20

Longitudinal research has also found that liver/bile duct and lung are the most common cancer sites among Aboriginal and Torres Strait Islander adults living in remote communities. Overall cancer incidence was significantly higher in Torres Strait Islander than Aboriginal people.10

8.7.3.3 Respiratory diseases

Aboriginal and Torres Strait Islander peoples experience significantly higher rates of respiratory diseases including asthma, chronic obstructive pulmonary disease (COPD), and pneumonia,2 all of which are directly caused by smoking.13 In 2011–15, 8% of Indigenous deaths were caused by respiratory disease—twice the non-Indigenous rate—and it was the fifth leading cause of Indigenous deaths. There has been a significant decline in respiratory disease mortality rates among Indigenous Australians since 1998.1

In the Indigenous population in 2004–05, 34% of current smokers and 37% of ex-smokers aged 35 and over reported that they had a respiratory disease.19 Other contributing factors to respiratory and lung disease include living in dusty regions, or exposure to smoke from wood fires.21 These environmental factors may also be responsible for influencing disease rates in some Indigenous communities.

8.7.3.4 Diabetes

Diabetes is a chronic condition in which blood glucose levels become too high due to the body producing little or no insulin, or being unable to use insulin properly.22 As well as being life threatening in its own right, diabetes mellitus (also known as type 2 diabetes) can lead to a range of other serious health problems, including coronary heart disease, stroke, peripheral vascular disease, kidney disease, eye disease,23 and complications in pregnancy and childbirth.24 The 2014 US Surgeon General’s report concluded that smoking is a cause of diabetes.13 Smokers with diabetes are also at increased risk of illness and premature death, mainly through the development of cardiovascular disease in its various forms.25 Being overweight, having an unbalanced diet and lack of physical activity are major risk factors for developing diabetes,26, 27 and each is more common in the Indigenous than the non-Indigenous population,14 and among Indigenous smokers than Indigenous non-smokers.19

In 2012–13, 11% of Indigenous Australians aged 18 years and over had diabetes, while an additional 4.7% were at risk of developing diabetes. After adjusting for age, Indigenous adults were 3.3 times as likely to have diabetes as non-Indigenous adults. During the period 2011–15, 8% of Indigenous deaths were due to diabetes, and death rates from diabetes were 6 times the non-Indigenous rate. Diabetes was the second leading cause of the gap in death rates behind circulatory disease. There has been no decrease in death rates from diabetes for Indigenous Australians over the last 17 years.1

In 2004–05, more than 1 in 10 (13% of) Indigenous people aged 35 or more who were current smokers reported having diabetes or high sugar levels. Ex-smokers were twice as likely to report having diabetes or high sugar levels compared with current smokers. Ex-smokers with diabetes or high sugar levels were also twice as likely to be overweight or obese compared with smokers with the same conditions, possibly reflecting quitting behaviour following diagnosis.19

8.7.3.5 Smoking in pregnancy, and maternal and child health outcomes

As noted in Sections 8.3 and 8.6, national and state data and local-level studies show that Indigenous women have a higher prevalence of smoking during pregnancy and after giving birth than non-Indigenous women.

Smoking in pregnancy is a major risk factor for preterm delivery, complications in childbirth, foetal growth restriction, stillbirth, low birthweight and infant mortality.28 Poorer health outcomes in pregnancy—low birthweight, premature birth, and stillbirth or death in the first four weeks of life (perinatal deaths)—are more prevalent among Aboriginal and Torres Strait Islander women than non-Indigenous women.14, 29 In 2014, low birthweight was almost twice as common among live born babies born to Aboriginal and Torres Strait Islander mothers as among those born to a non-Indigenous mother (11.8% compared with 6.2%).1 Infants who are born small for their gestational age are more likely to suffer a range of adverse health outcomes including having an impaired immune system, increased mortality and ill-health in infancy, and subnormal growth patterns.30

In the period 2011–15, the mortality rate for Indigenous infants was 1.9 times the non-Indigenous rate. The Indigenous infant mortality rate has more than halved, from 13.5 to 6.3 per 1,000 live births, between 1998 and 2015. The gap between mortality rates for Indigenous infants and non-Indigenous infants narrowed significantly (by 84%).1 Medical care improvements such as access to hospital birthing facilities, improved neonatal and paediatric care, and the establishment of pre-natal screening for congenital abnormalities have likely contributed to this decrease.31

The most common causes of death for Aboriginal and Torres Strait Islander infants were conditions originating in the perinatal period (51%) such as birth trauma, foetal growth disorders, complications of pregnancy, and respiratory and cardiovascular disorders specific to the perinatal period. The second leading cause of death was signs, symptoms and ill-defined conditions (21%), including SIDS.1 The risks of both these categories are elevated by smoking during pregnancy. Other than smoking, factors that affect maternal and child health outcomes include socio-economic circumstances, access to healthcare facilities, and the mother’s age during pregnancy.32 In 2015, one quarter of teenage mothers identified as Aboriginal and/or Torres Strait Islander, while comprising only 5% of the female population in the same age group. Compared with their non-Indigenous counterparts, Indigenous mothers were more likely to live in remote areas; to attend fewer medical appointments; to smoke; to have diabetes; and to have pre-term and low-birthweight babies.33

A limited number of studies have specifically looked at birth outcomes in relation to smoking during pregnancy among Aboriginal and Torres Strait Islander mothers. A South Australian study concluded that about 20% of preterm births, 48% of babies being born small for their gestational age, and 35% of babies with low birthweight could be attributed to smoking in this population group. Among non-Indigenous births, 11% of preterm births, 21% of babies small for gestational age and 23% with low birthweight could be attributed to maternal smoking.34 A Queensland study investigating the effect of smoking on preterm births and low birthweight found that both Indigenous and non-Indigenous smokers had poorer birth outcomes than non-smokers; there was no significant difference in birth outcomes between Indigenous and non-Indigenous smokers.35 Other studies of Indigenous birth outcomes have found significant associations between smoking and small for gestational age,36 low birthweight,37 and ‘poor birth outcomes’ (low birthweight and/or preterm).38 A Western Australian study found that the risk of sudden infant death syndrome for babies born to Indigenous mothers who smoke is nearly three times greater than for babies of non-smoking Indigenous women.39 An analysis of 2009–11 perinatal data found that, excluding pre-term and multiple births, smoking was responsible for 51% of low birthweight births to Indigenous mothers, compared with 19% for non-Indigenous mothers. After adjusting for a range of demographic factors, it was estimated that the proportion of low birthweight babies could be reduced by about one quarter if the smoking rate among Indigenous pregnant women was the same as it was for non-Indigenous mothers. Babies born to Indigenous mothers who smoked were 1.4 times as likely to be pre-term as those who did not smoke.2 Research in Queensland found that, after excluding pre-term and multiple births, 76% of Indigenous mothers who gave birth to a low birthweight baby reported smoking during pregnancy.40

8.7.4 Exposure to secondhand smoke and its health effects

Secondhand tobacco smoke also poses a major health risk. Babies and children exposed to cigarette smoke in the home experience higher rates of sudden infant death syndrome, exacerbation of asthma, a greater risk of developing acute lower respiratory tract infections such as bronchitis and pneumonia, and increased risk of middle ear infections. Adults exposed to secondhand smoke are more likely to develop a range of diseases including coronary heart disease, lung cancer and other respiratory problems.41 (See Chapter 4).

In 2014–15, about 58% of Indigenous children aged 0–14 lived with a daily smoker: a significant decrease from 63% in 2008. About 13% of Indigenous children lived with someone who smoked inside the home. These proportions increased with remoteness, such that Indigenous children in remote areas were significantly more likely to live with a daily smoker, and to live with a daily smoker who smoked indoors, than those in non-remote areas. Data from 2012–13 showed that Indigenous children were five times more likely than non-Indigenous children to live with a daily smoker who smoked inside the home (16% vs. 3% of non-Indigenous children).12 In terms of older children and adults, 60% of Aboriginal and Torres Strait Islander people aged 15 years and over were living in a household in which there was at least one daily smoker in 2014–15, down from 68% in 2008. Almost one in five (19%) were living in a household in which someone smoked inside.42

Aboriginal and Torres Strait Islander women are more likely than non-Indigenous women to be exposed to secondhand smoke during pregnancy, and this may impact on birth outcomes (see Section 4.16). A study of pregnant Aboriginal women in Western Australia reported an association between exposure to secondhand smoke and an increased risk of having low birthweight and/or preterm babies.38 Similarly, a 2015 study detected serum cotinine (which indicates exposure to cigarette smoke) in just over half of a sample of pregnant Indigenous women, and this was negatively associated with birth weight and gestational age at delivery.43 In a study of maternal smoking in the Northern Territory, 31% of the households of the pregnant participants included people who smoked inside during the pregnancy. Importantly, the birth of the child was associated with many of these households becoming smokefree indoors, with 12% reporting smoking indoors at one month after the birth, and 16% at seven months.44 In a 2013 qualitative study, Indigenous participants described avoiding smoking if children were present, and often limited the household areas where they smoked in an attempt to protect babies and children. Some also reported showering or changing clothes after having a cigarette.45

Smaller regional studies have also reported that babies born to Indigenous families are significantly more likely to be exposed to secondhand tobacco smoke in the home than non-Indigenous babies. Research from Western Australia found that 80% of Indigenous babies in a sample studied in Perth were regularly exposed to tobacco smoke.46 A study from Queensland found that 40% of Indigenous infants were exposed to smoke in the home, compared to 20% of non-Indigenous babies.47 Research from three remote top end (north Northern Territory) communities reported that 98% of Indigenous primary or high school-aged children lived with at least one smoker, and 43% lived with five or more smokers.48 Indigenous children have more than three times the incidence of ear and hearing problems of non-Indigenous children,14 for which secondhand smoke is likely to be at least partially responsible. A Western Australian study found that exposure to secondhand smoke was a significant predictor of otitis media (middle ear infection) in Aboriginal children,49which is common and frequently severe in Indigenous children,50 and is likely one of the key determinants of the high rates of disability and learning difficulties among this population.51

The comparatively high smoking rates among Indigenous adults mean that many Aboriginal and Torres Strait Islander children live in households where smoking is the norm, which is not only likely to affect their health, but also their likelihood of smoking (see Section 8.4.3).

Recent news and research

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3.Australian Institute of Health and Welfare, Australian burden of disease study: Impact and causes of illness and death in Aboriginal and Torres Strait Islander people 2011. Australian Burden of Disease Study series no. 6. Cat. no. BOD 7. Canberra: AIHW; 2016. Available from: http://www.aihw.gov.au/publication-detail/?id=60129557110

7.Unwin C, Thomson N, and Gracey M. The impact of tobacco smoking and alcohol consumption on Aboriginal mortality and hospitalisation in Western Australia: 1983–1991. Perth: Health Department of Western Australia, 1994.

10.Li M, Roder D, and McDermott R. Diabetes and smoking as predictors of cancer in Indigenous adults from rural and remote communities of North Queensland - a 15-year follow up study. International Journal of Cancer, 2018. Available from: https://www.ncbi.nlm.nih.gov/pubmed/29582412

13.U.S. Department of Health and Human Services. The Health consequences of smoking: 50 years of progress. A Report of the surgeon general. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014. Available from: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf

16.Guest C, O'Dea K, Carlin J, and Larkins R. Smoking in aborigines and persons of European descent in southeastern Australia: Prevalence and associations with food habits, body fat distribution and other cardiovascular risk factors. Australian Journal of Public Health, 1992; 16:397–402. Available from: http://www.ncbi.nlm.nih.gov/pubmed/1296789

17.Hoy W, Norman R, Hayhurst B, and Pugsley D. Health profile of adults in a Northern Territory Aboriginal community, with an emphasis on preventable morbidities. Australian and New Zealand Journal of Public Health, 1997; 21(2):121−6. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9161065

28.US Department of Health and Human Services. The health consequences of smoking. A report of the Surgeon General. Rockville, Maryland: US Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 2004. Available from: http://www.surgeongeneral.gov/library/smokingconsequences/

34.Chan A, Keane R, and Robinson J. The contribution of maternal smoking to preterm birth, small for gestational age and low birthweight among Aboriginal and non-Aboriginal births in South Australia. Medical Journal of Australia, 2001; 174(8):389–93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11346081

37.Humphrey M and Holzheimer D. A prospective study of gestation and birthweight in Aboriginal pregnancies in far north Queensland. Australian and New Zealand Journal of Obstetrics and Gynaecology, 2000; 40(3):326–30. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11065042

39.Freemantle J, Stanley F, Read A, and de Klerk N. The first research report: Patterns and trends in mortality of Western Australian infants, children and young people 1980−2002. Perth: Advisory Council on the Prevention of Deaths of Children and Young People, Department for Community Development, Government of Western Australia, 2004.

41.US Department of Health and Human Services. The health consequences of involuntary exposure to tobacco smoke: A report of the surgeon general. Atlanta, Georgia: US Department of Health and Human Services, Centers for Disease Control and Prevention, Coordinating Center for Health Promotion, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2006. Available from: http://www.surgeongeneral.gov/library/secondhandsmoke/